Healthcare Professionals
Improving coordination of healthcare, communication and patient/caregiver knowledge by fostering community-based coalitions, teamwork and patient-centered care.
Recommended Evidence-Based Interventions and Best Practices:
IPRO has built the foundation for our Care Transitions project on bringing healthcare providers from various settings together to evaluate existing transitional care systems and processes. Through our experience in the Upper Capital Region of NY, we emphasized building partnerships and collaboration among this diverse community to prioritize improved communication and care coordination. Our expertise has been convening cross-setting community meetings that include hospitals, home health agencies, nursing homes, dialysis centers, physician offices, community service organizations, and consumers. We promote and support the implementation of evidenced based interventions and best practices that improve care transitions for Medicare beneficiaries in the community.
- Care transition intervention coach model (Dr. Eric Coleman)
- Transitional care nurse model (Dr. Mary Naylor)
- Project RED (Re-Engineered Discharge)
- Project BOOST (Better Outcomes for Older adults through Safe Transitions)
- INTERACT II
- The IPAL Project: Improving palliative care
- Get Palliative Care.org
- Medication reconciliation across care settings
- Best Practices Intervention Package (BPIP): Transitional care coordination
- Transforming Care at the Bedside
- The Bridge Model
- The Guided Care Model
- Standardize patient information transfer at time of transition
- Use of electronic health record for patient information transfer
- Palliative care/Advance care planning consultation (MOLST)
- Palliative Care
- Post Acute Physician follow-up appointment within 7 days of hospital discharge
- Teachback
- Telephone follow-up post hospital discharge using the Care Transition Measure (CTM) -3 or CTM-15
- Telemedicine
- Multidisciplinary plan of care at time of hospital discharge
- Standardized clinical protocols, guidelines across settings
- Personal health record
- Patient Activation Measure
- Past Success
Initiatives
- Cardiovascular Health
- Care Coordination
- Community Based Sepsis
- Diabetes Self-Management
- Drug Safety
- Immunization
- MAPPP
- Nursing Home Quality
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- Nursing Home Quality (NY)
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- QAPI Self-Assessment
- CASPER Data
- Eliminating Inappropriate Antipsychotic Medication Use
- Clinical Quality Measures (QM)
- Composite Measure Score
- NHQCC Collaborative I Kick-Off
- NHQCC Collaborative I Outcomes Congress
- QI/QAPI
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- Using a System's Approach to Quality & Performance Improvement
- Nursing Home Quality Care Collaborative (NHQCC) Learning
- Engaging Staff in Individualized Care
- QAPI Self-Assessment and Related Resources
- QAPI In Action
- Quality Improvement (QI) Resources
- Quality Improvement Strategies
- Steps to QAPI
- Elements for Framing QAPI in Nursing Homes
- Clinical Topics
- Resources
- Consumers
- Nursing Home Quality (DC)
- Nursing Home Quality (SC)
- Outpatient Antibiotic Stewardship
- Quality Payment Program
- Transforming End of Life
Contact Us
New York
Sara Butterfield, Senior Director
518-320-3504
Sara.Butterfield@area-I.hcqis.org
Christine Stegel, Senior Quality Improvement Specialist
518-320-3513
Christine.stegel@area-I.hcqis.org
Fred Ratto Jr., Quality Improvement Specialist
518-320-3506
Fred.ratto@area-I.hcqis.org